Apparatus and method for reconstructing a ligament

ABSTRACT

A method and apparatus for reconstructing a ligament using a graft ligament support block which comprises a body, and a graft hole and a transverse fixation pin hole extending through the body, with both the graft hole and the fixation pin hole preferably extending substantially perpendicular to the longitudinal axis of the body. A graft ligament is looped through the graft hole, and the support block is advanced into the bone tunnel, with the two free ends of the looped graft ligament extending back out the bone tunnel. Next, a transverse tunnel is formed in the host bone, with the transverse tunnel being aligned with the fixation pin hole. Then the support block is secured in place by pinning the support block within the tunnel, i.e., by advancing a fixation pin along the transverse tunnel in the host bone and into the fixation pin hole in the support block.

REFERENCE TO PENDING PRIOR PATENT APPLICATION

This patent application claims benefit of pending prior U.S. ProvisionalPatent Application Ser. No. 60/326,351, filed Oct. 1, 2001 by Paul Re etal. for APPARATUS AND METHOD FOR RECONSTRUCTING A LIGAMENT (Attorney'sDocket No. SCAN-2 PROV), which patent application is hereby incorporatedherein by reference.

FIELD OF THE INVENTION

This invention relates to surgical apparatus and procedures in general,and more particularly to surgical apparatus and procedures forreconstructing a ligament.

BACKGROUND OF THE INVENTION

A ligament is a piece of fibrous tissue which connects one bone toanother.

Ligaments are frequently damaged (e.g., detached or torn or ruptured,etc.) as the result of injury and/or accident. A damaged ligament cancause instability, impede proper motion of a joint and cause pain.

Various procedures have been developed to repair or replace a damagedligament. The specific procedure used depends on the particular ligamentwhich is to be restored and on the extent of the damage.

One ligament which is frequently damaged as the result of injury and/oraccident is the anterior cruciate ligament (i.e., the ACL). Lookingfirst at FIGS. 1 and 2, it will be seen that the ACL 5 extends betweenthe top of the tibia 10 and the bottom of the femur 15. A damaged ACLcan cause instability of the knee joint and cause substantial pain andarthritis.

Numerous procedures have been developed to restore a damaged ACL througha graft ligament replacement. In general, and looking next at FIG. 3,these ACL replacement procedures involve drilling a bone tunnel 20 upthrough tibia 10 and drilling a bone tunnel 25 up into femur 15. In somecases the femoral tunnel 25 may be in the form of a blind hole andterminate in a distal end surface 30; in other cases the femoral tunnel25, or an extension of the femoral tunnel 25, may pass completelythrough femur 15. Once tibial tunnel 20 and femoral tunnel 25 have beenformed, a graft ligament 35, consisting of a harvested or artificialligament or tendon(s), is passed up through tibial tunnel 20, across theinterior of the knee joint, and up into femoral tunnel 25. Then a distalportion of graft ligament 35 is secured in femoral tunnel 25 and aproximal portion of graft ligament 35 is secured in tibial tunnel 20.

There are currently a number of different ways to secure a graftligament in a bone tunnel. One way is to use an interference screw 40(FIG. 4) to wedge the graft ligament against an opposing side wall ofthe bone tunnel. Another way is to suspend the graft ligament in thebone tunnel with a button 45 and a suture 50 (FIG. 5) or with a crosspin55 (FIG. 6). Still another way is to pass the graft ligament completelythrough the bone tunnel and affix the graft ligament to the outside ofthe bone with a screw 60 and washer 65 (FIG. 7) or with a staple (notshown).

The “Gold Standard” of ACL repair is generally considered to be theso-called “Bone-Tendon-Bone” fixation. In this procedure, a graft of thepatella tendon is used to replace the natural ACL. Attached to theopposing ends of the harvested tendon are bone grafts, one taken fromthe patient's knee cap (i.e., the patella) and one taken from thepatient's tibia (i.e., at the location where the patella tendon normallyattaches to the tibia). The graft ligament is then deployed in the bonetunnels, with one bone graft being secured in the femoral tunnel with aninterference screw and the other bone graft being secured in the tibialtunnel with another interference screw. Over the years, this procedurehas generally yielded a consistent, strong and reliable ligament repair.However, this procedure is also generally considered to be highlyinvasive and, in many cases, quite painful, and typically leavesunsightly scarring on the knee and a substantial void in the knee cap.

As a result, alternative procedures have recently been developed thatincorporate the use of soft tissue grafts such as the hamstring tendon.However, soft tissue grafts such as the hamstring can be difficult tostabilize within a bone tunnel. More particularly, the use of aninterference screw to aggressively wedge the hamstring against anopposing side wall of the bone tunnel can introduce issues such as graftslippage, tendon winding, tissue necrosis and tendon cutting.Furthermore, the use of a suture sling (e.g., such as that shown in FIG.5) and/or a crosspin (e.g., such as that shown in FIG. 6) to suspend thehamstring within the bone tunnel can introduce a different set ofissues, e.g., it has been found that the suture sling and/or crosspintend to permit the graft ligament to move laterally within the bonetunnel, with a so-called “windshield wiper” effect, thereby impedingingrowth between the graft ligament and the host bone and/or causingabrasion and/or other damage to the graft tissue. In addition, the useof a crosspin (e.g., such as that shown in FIG. 6) to secure a hamstringwithin the bone tunnel can introduce still other issues, e.g.,difficulties in looping the hamstring over the crosspin, or tearing ofthe hamstring along its length during tensioning if and where thecrosspin passes through the body of the hamstring, etc.

SUMMARY OF THE INVENTION

As a result, one object of the present invention is to provide improvedapparatus for reconstructing a ligament, wherein the apparatus isadapted to permit the graft ligament to be fashioned out of various softtissue grafts, e.g., allografts, autografts, xenografts, bioengineeredtissue grafts or synthetic grafts, and further wherein the graft isintended to be secured in place using a transverse fixation pin.

Another object of the present invention is to provide an improved methodfor reconstructing a ligament, wherein the method is adapted to permitthe graft ligament to be fashioned out of various soft tissue grafts,e.g., allografts, autografts, xenografts, bioengineered tissue grafts orsynthetic grafts, and further wherein the graft is intended to besecured in place using a transverse fixation pin.

These and other objects are addressed by the present invention whichcomprises, in one preferred form of the invention, the provision and useof a graft ligament support block which comprises a body, and a grafthole and a transverse fixation pin hole extending through the body, withboth the graft hole and the transverse fixation pin hole preferablyextending substantially perpendicular to the longitudinal axis of thebody. In one preferred form of the invention, the invention alsocomprises an installation tool for inserting the graft ligament supportblock into the bone tunnel and, while supporting the graft ligamentsupport block in the bone tunnel, forming a transverse tunnel in thehost bone, with the transverse tunnel in the host bone being alignedwith the transverse fixation pin hole in the graft ligament supportblock.

In one preferred method of use, a graft ligament is looped through thegraft hole in the graft ligament support block, and the graft ligamentsupport block is mounted to the installation tool. The two free ends ofthe graft ligament are then preferably secured to a proximal portion ofthe installation tool under tension, whereby to tie down the two freeends of the graft ligament. In addition to controlling the two free endsof the graft ligament, this arrangement will also help hold the graftligament support block to the installation tool. Then the installationtool is used to advance the graft ligament support block through thetibial tunnel, across the interior of the knee joint, and up into thefemoral tunnel, with the two free ends of the looped graft ligamentextending back out through the tibial tunnel. Next, a transverse tunnelis formed in the host bone, with the transverse tunnel being alignedwith the transverse fixation pin hole in the graft ligament supportblock. Then the graft ligament support block is secured in place bypinning the graft ligament support block within the femoral tunnel,i.e., by advancing a transverse fixation pin along the transverse tunnelin the host bone and into the transverse fixation pin hole in the graftligament support block. Then the two free ends of the looped graftligament are released from the installation tool, the installation toolis detached from the graft ligament support block, and the installationtool is withdrawn from the surgical site. Finally, the two free ends ofthe looped graft ligament are secured to the tibia, thus completing theACL repair. If desired, the tibial attachment can be effected using asecond graft ligament support block.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other objects and features of the present invention will bemore fully disclosed or rendered obvious by the following detaileddescription of the preferred embodiments of the invention, which is tobe considered together with the accompanying drawings wherein likenumbers refer to like parts and further wherein:

FIG. 1 is a schematic view of a knee joint, as viewed from the anteriorside;

FIG. 2 is a schematic view of a knee joint, as viewed from the posteriorside;

FIG. 3 is a schematic view of a generic ACL reconstruction;

FIG. 4 is a schematic view of an ACL reconstruction effected using aninterference screw;

FIG. 5 is a schematic view of an ACL reconstruction effected using asuture sling;

FIG. 6 is a schematic view of an ACL reconstruction effected using acrosspin;

FIG. 7 is a schematic view of an ACL reconstruction effected using ascrew and washer;

FIG. 8 is a schematic view of a graft ligament support block formed inaccordance with the present invention;

FIG. 9 is a partially exploded view showing the graft ligament supportblock of FIG. 8 and an installation tool for deploying the same;

FIGS. 10-12 are various views showing the graft ligament support blockof FIG. 8 mounted to the distal end of the installation tool shown inFIG. 9;

FIG. 13 is a partial perspective view showing details of the proximalend of the installation tool shown in FIG. 9;

FIG. 14 is a side view, partially in section, showing further details ofthe construction of the installation tool shown in FIG. 9;

FIG. 15 is a side sectional view of the installation tool's drillsleeve;

FIG. 16 is a perspective view of a transverse fixation pin which may beused in conjunction with the graft ligament support block of FIG. 8 andthe installation tool of FIG. 9;

FIGS. 17-33 are a series of schematic views showing an ACLreconstruction being effected in accordance with the present invention;

FIG. 34 is a schematic view showing another form of graft ligamentsupport block formed in accordance with the present invention;

FIG. 35 is an enlarged side view showing an alternative construction fora portion of the installation tool;

FIG. 36 is a sectional view taken along line 36-36 of FIG. 35;

FIG. 37 is a schematic view showing a reamer drill guide formed inaccordance with the present invention;

FIG. 38 is a schematic view showing the reamer element of the reamerdrill guide shown in FIG. 37; and

FIGS. 39-44 are a series of schematic views showing an ACLreconstruction being effected in accordance with the present invention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

Looking next at FIG. 8, there is shown a graft ligament support block100 which comprises one preferred form of the invention. Graft ligamentsupport block 100 comprises a body 105, and a graft hole 110 and atransverse fixation pin hole 115 extending through body 105, with bothgraft hole 110 and transverse fixation pin hole 115 preferably extendingsubstantially perpendicular to the longitudinal axis 120 of body 105. Inone preferred form of the invention, graft hole 110 and transversefixation pin hole 115 extend diametrically across body 105, with grafthole 110 and transverse fixation pin hole 115 extending substantiallyparallel to one another. Preferably graft hole 110 resides closer to theproximal end 125 of body 105 than transverse fixation pin hole 115, andtransverse fixation pin hole 115 resides closer to the distal end 130 ofbody 105 than graft hole 110. In one preferred form of the invention,the distal end of body 105 has a circular cross-section, although it mayalso have an oval cross-section or a polygonal cross-section (e.g.,square or rectangular or triangular, etc.). In one preferredconstruction, the distal end of body 105 has a cross-section sized justslightly smaller than the diameter of the bone tunnel, so as to providea close interface between body 105 and the walls of the bone tunnel. Inone preferred form of the invention, the distal end 130 of body 105 istapered so as to facilitate advancement of graft ligament support block100 through a bone tunnel. And in a preferred form of the invention, theproximal end of body 105 is sculpted away, e.g. such as shown at 135, soas to provide more room for a graft ligament looped through graft hole110 and extending distally therefrom. Body 105 also includes a pair ofrecesses 140 for mounting body 105 to an appropriate installation tool,as will hereinafter be discussed in further detail.

If desired, graft ligament support block 100 may also include suturehole 145 for receiving a tow suture, as will hereinafter be discussed infurther detail.

Additionally, if desired, the proximal end of graft hole 110 may betapered as shown at 150 so as to provide a less traumatic bearingsurface for a graft ligament looped through graft hole 110, and/or theentrance of transverse fixation pin hole 115 may be tapered as shown at155 so as to facilitate entry of a transverse fixation pin intotransverse fixation pin hole 115.

Body 105 may be formed out of a polymer, a bioabsorbable orbioremodelable material, allograft bone, a metal, a ceramic, coral, afiber composite, a composite including at least one of the foregoing,etc. By forming body 105 out of a relatively strong material, the graftligament can be held under tension even where body 105 is relativelysmall, or where one or more of the holes 110, 115 and/or 145 is locatedfairly close to the periphery of body 105.

Looking next at FIGS. 9-15, there is shown an installation tool 200which may be used in conjunction with graft ligament support block 100.Installation tool 200 generally comprises a holder 205 and an associateddrill guide 210.

Holder 205 comprises a shaft 215 having a pair of finger 220 at itsdistal end and a handle 225 at its proximal end. Fingers 220 allowinstallation tool 200 to mate with, and releasably hold, graft ligamentsupport block 100 by selectively fitting into the recesses 140 (FIG. 8)formed on the proximal end of graft ligament support block 100. SeeFIGS. 9-12 and 14. In essence, fingers 220 and recesses 140 comprise amale/female connection; if desired, the locations of the male and femalemembers may be reversed (i.e., with the male portion on support block100 and the female portion on holder 205); or an alternative type ofconnection (e.g., a grasper) may be used. Preferably one or more sutureposts 227 are formed on the proximal end of shaft 215 adjacent to handle225. Suture posts 227 allow the two free ends of a graft ligament to besecured to the installation tool, as will hereinafter be discussed infurther detail. Handle 225 allows installation tool 200 to beconveniently grasped by a user. Handle 225 includes a post hole 230.Post hole 230 allows drill guide 210 to be releasably secured to holder205, as will hereinafter be discussed in further detail.

Drill guide 210 comprises an outrigger 235 having a threaded bore 240(FIG. 14) formed in its distal end 245, and a slot 250 (FIG. 9) and post255 at its proximal end 260. The end of post 255 is threaded, e.g., asshown at 265.

The threaded bore 240 (FIG. 14) in the outrigger's distal end 245 issized to receive a drill sleeve 270 therein. Drill sleeve 270 hasthreads 275 along its length and terminates in a proximal head 280. Head280 can be used to manually rotate drill sleeve 270 within theoutrigger's threaded bore 240, whereby to move drill sleeve 270 relativeto the distal end 245 of outrigger 235. A lumen 285 extends throughdrill sleeve 270.

Slot 250 and post 255 permit outrigger 235 to be releasably mounted toholder 205. More particularly, outrigger 235 may be mounted to holder205 by fitting the holder's shaft 215 in the outrigger's slot 250 (FIGS.13 and 14), fitting the outrigger's post 255 in the holder's post hole230, and then tightening nut 290 onto the threaded end 265 of post 255.

As will hereinafter be described, graft ligament support block 100 andinstallation tool 200 are intended to be used in conjunction with atransverse fixation pin. One preferred transverse fixation pin 300 isshown in FIG. 16. Transverse fixation pin 300 generally comprises asolid shaft 305 terminating in a tapered distal end 310, and a ribbed(or barbed or threaded) section 315. A non-circular socket 320 is formedin the proximal end of transverse fixation pin 300, whereby transversefixation pin 300 may be engaged by a driver.

An ACL reconstruction effected in accordance with the present inventionwill now be described.

First, the surgical site is prepared for the graft ligament, e.g., byclearing away the damaged ACL, etc. Then a guidewire 400 (FIG. 17) isdrilled up through tibia 10 and into the interior of the knee joint.Preferably guidewire 400 is stopped short of engaging the bottom offemur 15 (FIG. 18). Then a cannulated tibial drill 500 (FIG. 19) isloaded onto guidewire 400 and drilled up through tibia 10 and into theinterior of the knee joint (FIG. 20). Then cannulated tibial drill 500is withdrawn back down the guidewire (FIG. 21), leaving a tibial tunnel20.

Next, guidewire 400 is drilled an appropriate distance into the interiorof femur 15. If desired, guidewire 400 may be drilled all the waythrough femur 15 (FIG. 22), for reasons which will hereinafter bedescribed. Then a cannulated femoral drill 600 (e.g., an acorn drill) isloaded onto guidewire 400 (FIG. 22), passed through tibial tunnel 20,across the interior of the knee joint, and then drilled up into femur15, stopping within the interior of femur 15 (FIG. 23). Then cannulatedfemoral drill 600 is withdrawn back down the guidewire, leaving afemoral tunnel 25 (FIG. 24).

Next, a graft ligament 35 is mounted to graft ligament support block 100by threading one end of the graft ligament through graft hole 110, andthen graft ligament support block 100 is mounted to the distal end ofshaft 215, i.e., by seating fingers 220 in recesses 140. The two freeends of graft ligament 35 are preferably held taut, e.g., by passingsutures 70 through the two free ends of graft ligament 35 and thensecuring those sutures (e.g., by winding) to suture posts 227. Thisarrangement will help control the two free ends of graft ligament 35 andwill help hold graft ligament support block 100 to holder 205. Theninstallation tool 200 is used to push graft ligament support block 100,and hence graft ligament 35, up through tibial tunnel 20 (FIG. 25),across the interior of the knee joint, and up into femoral tunnel 25(FIG. 26).

If desired, all of the force required to advance graft ligament supportblock 100 and graft ligament 35 through tibial tunnel 20, across theinterior of the knee joint, and up into femoral tunnel 25 may besupplied by pushing distally on installation tool 200. Alternatively, ifguidewire 400 has been drilled completely through femur 15 (e.g., suchas is shown in FIG. 22), and if the proximal end of guidewire 400includes a suture eyelet (e.g., such as the suture eyelet 405 shown inFIGS. 23 and 24), a suture may be used to help tow graft ligamentsupport block 100 and graft ligament 35 up into position. Moreparticularly, a suture 700 (FIG. 25) may be looped through the suturehole 145 in graft ligament support block 100 and through suture eyelet405 on guidewire 400; then, by pulling distally on the portion ofguidewire 400 extending out of the top end of femur 15, suture 700 canbe used to help tow graft ligament support block 100 and graft ligament35 up into position (FIG. 26). Such an arrangement will help reduce theamount of force which needs to be delivered by installation tool 200 topush graft ligament support block 100 and graft ligament 35 up intoposition.

Once graft ligament support block 100 and graft ligament 35 have beenadvanced into position (FIG. 26), drill sleeve 270 is advanced intotight engagement with femur 15 (FIG. 27). This action will helpstabilize installation tool 200 relative to femur 15. Then a transversetunnel drill 800 (FIG. 28) is used to drill a transverse tunnel 75through the lateral portion of femur 15, through transverse fixation pinhole 115 in graft ligament support block 100, and into the medialportion of femur 15. In this respect it will be appreciated thattransverse tunnel drill 800 will be accurately and consistently directedthrough transverse fixation pin hole 115 in graft ligament support block100 (FIG. 28) due to the fact that the orientation of graft ligamentsupport block 100 and installation tool 200 (and hence drill sleeve 270)is regulated by the engagement of fingers 220 in recesses 140.

Once transverse tunnel drill 800 has been used to drill transversetunnel 75, transverse tunnel drill 800 is removed (FIG. 29). Then drillsleeve 270 is loosened and outrigger 210 dismounted from holder 205(FIG. 30). Then transverse fixation pin 300, mounted on a driver 325, isadvanced into transverse tunnel 75 and across transverse fixation pinhole 115 in graft ligament support block 100 (FIG. 31), whereby tosecure graft ligament support block 100 (and hence graft ligament 35) infemoral tunnel 25. Depending on whether section 315 of transversefixation pin 300 is ribbed or barbed or threaded, the transversefixation pin may be advanced by driver 325 by tapping on the proximalend of the driver with a mallet or by rotating the driver and/or both.The driver 325 is then removed (FIG. 32). Next, the two free ends ofgraft ligament 35 are detached from the handle's suture posts 227, andholder 205 is withdrawn (FIG. 33). In this respect it will beappreciated that graft ligament support block 100 will be held inposition in femoral tunnel 25 when holder 205 is withdrawn due to thepresence of transverse fixation pin 300 in transverse tunnel 75 andtransverse fixation pin hole 115. Finally, the two free ends of graftligament 35 are secured to tibia 10, thereby completing the ACLreconstruction procedure.

In the embodiment disclosed above, transverse fixation pin hole 115(FIG. 8) is pre-formed in body 105. Such a construction is generallyadvantageous, since it eliminates the need to drill through body 105after graft ligament support block 100 has been positioned in thefemoral tunnel and before transverse fixation pin 300 has been passedthrough body 105. In addition, by pre-forming transverse fixation pinhole 115 in body 105, transverse fixation pin hole 115 can be given adesired geometry, e.g., it permits the entrance to crosspin hole 115 tobe tapered, such as is shown at 155 in FIG. 8, whereby to help centertransverse fixation pin 300 in transverse fixation pin hole 115.However, it should also be appreciated that, if desired, transversefixation pin hole 115 may not be pre-formed in body 105. Instead,transverse fixation pin hole 115 may be formed in situ, at the time ofsurgery, e.g., by drilling across body 105 when forming transversetunnel 75 with transverse tunnel drill 800. Where transverse fixationpin hole 115 is to be formed in situ, it is of course necessary for body105 to be formed out of a drillable material. In addition, wheretransverse fixation pin hole 115 is to be formed in situ, it ispreferred that body 105 be formed out of a relatively strong material,since then any misplacement (i.e., any off-center placement) oftransverse fixation pin hole 115 will be well tolerated by body 105.

Additionally, in the embodiment disclosed above, the outer surface ofbody 105 is sculpted away proximal to graft hole 110, such as is shownat 135 in FIG. 8, so as to help accommodate the graft ligament infemoral tunnel 25. In FIG. 8, sculpting is effected so as to produce asubstantially planar surface at 135. However, if desired, sculpting canbe effected so as to provide alternative geometries, e.g., a surfacegroove, etc. Thus, for example, in FIG. 34 body 105 is shown with a pairof surface grooves 165 communicating with, and extending proximallyfrom, graft hole 110. Surface grooves 165 are sized so as to provide arecess for seating portions of the graft ligament as the graft ligamentextends proximally from graft hole 110.

Also, in the embodiment disclosed above, body 105 is shown (see, forexample, FIG. 8) as having a relatively smooth outer surface. However,if desired, body 105 may have spikes or ribs, etc. formed on a side wallthereof so as to help stabilize body 105 within the bone tunnel.

Furthermore, in the embodiment disclosed above, drill sleeve 270 ismovably connected to outrigger 235 via a screw connection (i.e., screwthreads 275 on the exterior of drill sleeve 270 and threaded bore 240 inoutrigger 235). This arrangement provides a simple and cost-effectiveway to movably secure drill sleeve 270 to outrigger 235. However, ifdesired, other types of arrangements could also be used. For example,and looking now at FIGS. 35 and 36, drill sleeve 270 could have a smoothor ribbed or roughed (e.g. knurled) exterior 275A that slides through anon-threaded bore 240A in outrigger 235, with a locking pin 235A beingselectively advanceable (through a threaded bore 235B) into engagementwith drill sleeve 270, whereby to selectively lock the drill sleeve tothe outrigger. Still other possible arrangements for selectively lockingdrill sleeve 270 to outrigger 235 will be apparent to those skilled inthe art of drilling and drill sleeves.

Also, in the embodiment disclosed above, drill guide 210 is shown (see,for example, FIG. 14) as being releasably secured to holder 205 via apost 255 and tightening nut 290. However, it should be appreciated thatother types of connections (e.g., a “quick release” clamping mechanism)may also be used to releasably secure drill guide 210 to holder 205.

It is also possible to form transverse tunnel 75 before graft ligamentsupport block 100 and graft ligament 35 are positioned in femoral tunnel25. More particularly, in one possible arrangement, a reamer drill guide200A (FIG. 37) may be used. Reamer drill guide 200A is substantiallyidentical to the installation tool 200 described above, except as willhereinafter be described. More particularly, reamer drill guide 200Acomprises a reamer 205A and the drill guide 210. Reamer 205A issubstantially identical to the holder 205 described above, except thatit has a cylindrical element 220A (FIGS. 37 and 38) at its distal endhaving a transverse hole 220B extending therethrough, and it omits thesuture posts 227 which are preferably provided on holder 205. Reamer205A is configured so that (i) its cylindrical element 220A has adiameter approximately equal to the diameter of femoral tunnel 25, and(ii) when drill guide 210 is attached to reamer 205A, the lumen 285 indrill sleeve 270 will be aligned with transverse hole 220B in reamer205A.

Graft ligament support block 100, holder 205 and reamer drill guide 200Amay be used to effect an ACL reconstruction as follows.

First, the surgical site is prepared for the graft ligament, e.g., byclearing away the damaged ACL, etc. Then a guidewire 400 (FIG. 17) isdrilled up through tibia 10, across the interior of the knee joint.Preferably guidewire 400 is stopped short of engaging the bottom offemur 15 (FIG. 18). Then a cannulated tibial drill 500 (FIG. 19) isloaded onto guidewire 400 and drilled up through tibia 10 and into theinterior of the knee joint (FIG. 20). Then cannulated tibial drill 500is withdrawn back down the guidewire (FIG. 21), leaving a tibial tunnel20.

Next, guidewire 400 is drilled an appropriate distance into the interiorof femur 15. Then a cannulated femoral drill 600 (e.g., an acorn drillof the type shown in FIG. 22) is loaded onto guidewire 400, passedthrough tibial tunnel 20, across the interior of the knee joint, andthen drilled up into femur 15, stopping within the interior of femur 15.Then cannulated femoral drill 600 is withdrawn back down the guidewire,leaving a femoral tunnel 25, and then guidewire 400 is withdrawn (seeFIG. 39).

Next, reamer drill guide 200A is advanced so that its cylindricalelement 220A is advanced through tibial tunnel 20, across the interiorof the knee, and up into femoral tunnel 25. In this respect it should beappreciated that as reamer drill guide 200A is advanced through tibialtunnel 20 and femoral tunnel 25, its cylindrical element 220A will reamboth bone tunnels, clearing out any intervening debris.

Once reamer drill guide 200A has been advanced into position, drillsleeve 270 is advanced into tight engagement with femur 15. This actionwill help stabilize reamer drill guide 200A relative to femur 15. Then atransverse tunnel drill 800 (FIG. 40) is used to drill a transversetunnel 75 through the lateral portion of femur 15, through transversehole 220B in cylindrical element 220A, and into the medial portion offemur 15. In this respect it will be appreciated that transverse tunneldrill 800 will be accurately and consistently directed throughtransverse hole 220B in cylindrical element 220A (FIG. 40) due to thefact that the relative orientation of cylindrical element 220A and drillsleeve 270 is regulated by the pre-defined engagement of drill guide 210with reamer 205A.

Once transverse tunnel drill 800 has been used to drill transversetunnel 75, transverse tunnel drill 800 is removed. Then drill sleeve 270is loosened and reamer drill guide 200A is withdrawn from the surgicalsite (FIG. 41).

Next, a graft ligament 35 is mounted to graft ligament support block 100by threading one end of the graft ligament through graft hole 110, andthen graft ligament support block 100 is mounted to the distal end ofshaft 215, i.e., by seating fingers 220 in recesses 140. The two freeends of graft ligament 35 are preferably held taut, e.g., by passingsutures 70 through the two free ends of graft ligament 35 and thensecuring these sutures (e.g., by winding) to suture posts 227. Thisarrangement will help control the two free ends of graft ligament 35 andwill help hold graft ligament support block 100 to holder 205. Thenholder 205 is used to push graft ligament support block 100, and hencegraft ligament 35, up through tibial tunnel 20, across the interior ofthe knee joint, and up into femoral tunnel 25 (FIG. 42). As graftligament support block is advanced in femoral tunnel 25, or after it hasbeen advanced an appropriate distance into femoral tunnel 25, it isrotated as necessary, by turning handle 225 as necessary, so as to alignthe transverse fixation pin hole 115 with transverse tunnel 75. Suchalignment may be facilitated by providing an alignment marker (e.g.,such as the alignment marker 225A shown in FIG. 43) on handle 225.

Then transverse fixation pin 300, mounted on a driver 325, is advancedinto transverse tunnel 75 and across transverse fixation pin hole 115 ingraft ligament support block 100 (FIG. 44), whereby to secure graftligament support block 100 (and hence graft ligament 35) in femoraltunnel 25. Then driver 325 is removed. Next, the two free ends of graftligament 35 are detached from the handle's suture posts 227, and holder205 is withdrawn. In this respect it will be appreciated that graftligament support block 100 will be held in position in femoral tunnel 25when holder 205 is withdrawn due to the presence of transverse fixationpin 300 in transverse tunnel 75 and transverse fixation pin hole 115.Finally, the two free ends of graft ligament 35 then secured to tibia10, thereby completing the ACL reconstruction procedure.

In the preceding discussion, the present invention has been discussed onthe context of an ACL reconstruction. However, it should also beappreciated that the present invention may also be used in connectionwith the other types of ligament reconstructions and/or other types ofanatomical reconstructions.

1. Apparatus for use in reconstructing a ligament, said apparatuscomprising: a graft ligament support block for supporting a graftligament in a bone tunnel, said graft ligament support block comprising:a body having a distal end, a proximal end, and a longitudinal axisextending between said distal end and said proximal end; a graft holeextending through said body transverse to said longitudinal axis andconfigured to receive a graft ligament therein; and a transversefixation pin hole extending through said body transverse to saidlongitudinal axis and configured to receive a transverse fixation pintherein.
 2. Apparatus according to claim 1 wherein said graft holeresides closer to said proximal end of said body than said transversefixation pin hole.
 3. Apparatus according to claim 1 wherein at least aportion of an opening of said graft hole is tapered so as to provide aless traumatic bearing surface for a graft ligament looped through saidgraft hole.
 4. Apparatus according to claim 1 wherein an opening of saidtransverse fixation pin hole is tapered so as to facilitate entry of atransverse fixation pin into said transverse fixation pin hole. 5.Apparatus according to claim 1 wherein at least a portion of said bodybetween said graft hole and said transverse fixation pin hole has asubstantially cylindrical cross-section.
 6. Apparatus according to claim1 wherein said distal end of said body is tapered so as to facilitateadvancement of said graft ligament support block through a bone tunnel.7. Apparatus according to claim 1 wherein said proximal end of said bodyis sculpted away so as to provide more room for a graft ligament loopedthrough said graft hole and extending proximally therefrom.
 8. Apparatusaccording to claim 7 wherein said proximal end of said body is sculptedaway so as to form at least one substantially planar surface. 9.Apparatus according to claim 7 wherein said proximal end of said body issculpted away so as to form at least one surface groove extendingbetween said graft hole and said proximal end of said body. 10.Apparatus according to claim 1 wherein said body is formed out of amaterial selected from the group consisting of a polymer, abioabsorbable material, a bioremodelable material, allograft bone, ametal, a ceramic, coral, a fiber composite, and a composite including atleast one of the foregoing.
 11. Apparatus according to claim 1 whereinsaid body further comprises at least one element for engagement by aninstallation tool.
 12. Apparatus according to claim 11 wherein said atleast one element comprises an opening formed in said proximal end ofsaid body and adapted for engagement by a finger formed on theinstallation tool.
 13. Apparatus according to claim 11 wherein said atleast one element comprises a finger extending proximally from saidproximal end of said body and adapted for engagement in an openingformed on the installation tool.
 14. Apparatus according to claim 1wherein said body further comprises a suture hole extending through saidbody transverse to said longitudinal axis and configured to receive atow suture therein.
 15. Apparatus according to claim 14 wherein saidsuture hole resides closer to said distal end of said body than saidtransverse fixation pin hole.
 16. Apparatus according to claim 1 furthercomprising an installation tool, said installation tool comprising: aholder, said holder comprising: a shaft having a distal end, a proximalend and longitudinal axis extending between said distal end and saidproximal end, said proximal end of said shaft comprising at least onefinger for engagement in said opening; and a handle mounted to saidproximal end of said shaft.
 17. Apparatus according to claim 16 furthercomprising at least one suture post formed on said proximal end of saidshaft.
 18. Apparatus according to claim 16 wherein said installationtool further comprises a drill guide adapted to be releasably secured tosaid holder.
 19. Apparatus according to claim 18 wherein said drillguide comprises: an outrigger comprising a distal end and a proximalend, with said proximal end of said outrigger being configured to bereleasably secured to said holder; and a drill sleeve moveably attachedto said distal end of said outrigger, said drill sleeve comprising adrilling lumen extending therethrough.
 20. Apparatus according to claim19 wherein said installation tool is configured so that when said graftligament support block is attached to said distal end of said shaft,said drilling lumen in said drill guide is aligned with said transversefixation pin hole in said body.
 21. Apparatus according to claim 16wherein said proximal end of said holder comprises an orientation markerfor visually indicating the axial orientation of said distal end of saidshaft.
 22. A method for securing a graft ligament in a bone tunnel,comprising the steps of: looping a graft ligament through a graft holein a graft ligament support block; advancing the graft ligament supportblock into the bone tunnel; forming a transverse tunnel in the hostbone, with a transverse tunnel being aligned with a transverse fixationpin hole in the graft ligament support block; and pinning the graftligament support block within the bone tunnel by advancing a transversefixation pin along the transverse tunnel in the host bone and into thetransverse fixation pin hole in the graft ligament support block.
 23. Amethod according to claim 22 wherein an installation tool is used toadvance the graft ligament support block into the bone tunnel.
 24. Amethod according to claim 23 wherein the two free ends of the graftligament are secured to the installation tool prior to advancing thegraft ligament support block into the bone tunnel.
 25. A methodaccording to claim 23 wherein the installation tool is used to form thetransverse tunnel in the host bone.
 26. A method according to claim 22wherein a tow suture is used to advance the graft ligament support blockinto the bone tunnel.
 27. A method for securing a graft ligament in abone tunnel, said method comprising the steps of: forming a transversetunnel in the host bone; looping a graft ligament through a graft holein a graft ligament support block; advancing the graft ligament supportblock into the bone tunnel so that a transverse fixation pin hole in thegraft ligament support block is aligned with the transverse tunnel; andpinning the graft ligament support block within the bone tunnel byadvancing a transverse fixation pin along the transverse tunnel in thehost bone and into the transverse fixation pin hole in the graftligament support block.
 28. A method according to claim 27 wherein aninstallation tool is used to advance the graft ligament support blockinto the bone tunnel.
 29. A method according to claim 28 wherein the twofree ends of the graft ligament are secured to the installation toolprior to advancing the graft ligament support block into the bonetunnel.